The Laryngoscope

C 2014 The American Laryngological,

V
Rhinological and Otological Society, Inc.

Patterns in the Evaluation of Hoarseness: Time to Presentation,

Laryngeal Visualization, and Diagnostic Accuracy

Sarah E. Keesecker, MD; Thomas Murry, PhD; Lucian Sulica, MD

Objectives/Hypothesis: Controversial recommendations regarding the evaluation of dysphonia have been made in the
absence of evidence related to clinical practice. This study aims to describe existing patterns of care for dysphonia to gener-
ate data for potential systemic improvement and provide a baseline for dysphonia recommendations.
Study Design: Retrospective review.
Methods: Information regarding the current complaint, including duration of hoarseness; inciting factors; number and
type of previous physicians seen; Voice Handicap Index-10; and details of prior evaluation, diagnosis, and treatment was col-
lected from patient records.
Results: A total of 259 patients complaining of hoarseness were evaluated. Of those, 35.1% presented directly to sub-
specialty care, whereas 61% were previously evaluated by another otolaryngologist. Median times (in months) from symptom
onset to evaluation were as follows: initial evaluation, 3.0; laryngoscopy, 3.0; stroboscopic exam, 5.8; subspecialty evaluation,
6.6. A total of 64.5% of patients had at least one incoming diagnosis; 45% of all incoming diagnoses were revised on re-
evaluation. Diagnoses most commonly revised included “no abnormality,” edema or laryngopharyngeal reflux disease (LPR),
infection or allergy, and muscle tension dysphonia (MTD) or behavioral disorders. Final diagnoses that most frequently dif-
fered from incoming diagnoses were paresis; MTD or behavioral disorders; malignancy; and sulcus, atrophy, or scar.
Conclusions: Patients received prompt laryngeal visualization. However, we observed high rates of diagnostic error. Ini-
tial diagnoses of LPR, edema, infection, and allergy appear to be particularly likely to be revised on further evaluation; and
scar, sulcus, atrophy, and paresis are likely to be overlooked.
Key Words: Hoarseness, dysphonia, laryngoscopy, stroboscopy, diagnosis, guideline.
Level of Evidence: 4.
Laryngoscope, 00:000–000, 2014

INTRODUCTION Despite these considerations, there are no truly

Hoarseness (or dysphonia) affects nearly one-third
of the adult population at some point.1,2 Affected
patients present to a variety of physicians including pri-
mary care doctors, otolaryngologists, gastroenterologists,
pulmonologists, and even emergency rooms. Hoarseness
is a symptom, not a diagnosis, and effective treatment
recommendations cannot be made without determining
the underlying cause. The range of such causes is vast;
the more serious conditions require prompt treatment.
Visualization of the larynx is essential for assessing and
accurately diagnosing dysphonic patients.3
Additional Supporting Information may be found in the online
version of this article.
From the College of Physicians & Surgeons (S.E.K.), Columbia Uni-
versity; and the Parker Institute for the Voice, Dept. of Otolaryngology–
Head & Neck Surgery (T.M., L.S.), Weill Cornell Medical College, New
York, New York, U.S.A.
Editor’s Note: This Manuscript was accepted for publication
September 8, 2014.
Presented at the American Laryngological Association’s 2014
Spring Meeting at Combined Otolaryngological Spring Meetings (COSM)
in Las Vegas, Nevada on May 14–15, 2014.
This work was supported by a grant from the Doris Duke Charita-
ble Foundation to Columbia University Medical Center (S.E.K.). The
authors have no other funding, financial relationships, or conflicts of
interest to disclose.
Send correspondence to Sarah E. Keesecker, MD, 180 Fort
Washington Avenue, New York, NY 10032. E-mail: sek2157@columbia.edu
DOI: 10.1002/lary.24955
evidence-based guidelines regarding the evaluation of
hoarseness or appropriate referral to a subspecialist.
Meanwhile, controversial recommendations have been
made without regard to clinical practice, some of which
may negatively impact patient care. For example, the
American Academy of Otolaryngology Clinical Practice
Guidelines for hoarseness4 allow for a 3-month wait
period before patients with unresolved hoarseness
undergo laryngoscopy. This 3-month window could delay
appropriate diagnosis and treatment and allow malig-
nancies to progress.5 The recommendation appears to
have no basis in clinical practice or expert opinion. A
survey study of otolaryngologists found that the longest
delay to laryngoscopy averaged 12.96 days.6 A survey of
members of the American Laryngological Association,
the American Broncho-Esophagological Association, and
the European Laryngology Society recommended a man-
dated time to laryngoscopy of 1 week to 1 month for the
most acutely dysphonic patients, regardless of risk fac-
tors for malignancy, and no greater than 2 months in
any situation.7
Information regarding actual clinical practice may
offer a basis from which to establish and formalize algo-
rithms for the diagnosis and management of the hoarse
patient. This type of data may provide insights into cur-
rent patterns of evaluation and management and reveal
inefficiencies and opportunities for systemic improvement.

Laryngoscope 00: Month 2014 Keesecker et al.: Patterns in the Evaluation of Hoarseness
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The purpose of this study is to describe existing patterns TABLE I.
of care in patients with a chief complaint of hoarseness Demographic Information
presenting to a subspecialty care physician. The specific
Variable No. (%)
aims are to:
1. Evaluate median time from symptom onset to primary medi- Age
cal evaluation, specialty medical evaluation, initial laryngos- < 18 8 (3.1)
copy, and initial stroboscopic exam. 18–35 69 (26.6)
2. Investigate discrepancies in diagnosis between primary and 36–55 79 (30.5)
subspecialty care.
56–70 67 (25.9)
3. Analyze patterns of diagnosis to highlight areas that require
more specific attention. > 70 36 (13.9)
Sex
Male 112 (43.2)
Female 147 (56.8)
MATERIALS AND METHODS
This study was approved by the institutional review board Voice Use History
of Weill Cornell Medical College. A retrospective review was Performer 89 (34.4)
conducted on new patients with a chief complaint of hoarseness Nonperformer 170 (65.6)
presenting to the laryngology service of a university medical VHI Category
center in an urban area between July 16, 2013, and November
0–9 63 (26.4)
19, 2013. All patients were evaluated by the senior author (L.S.),
a fellowship-trained laryngologist, and received a final diagnosis 10–19 73 (30.5)
based on history, physical exam, and stroboscopy. Data was pri- 20–29 54 (22.6)
marily obtained from a standard intake form (Supp. App. S1; 30–40 49 (20.5)
online only). Where necessary, the chart was reviewed to aug- Number of Prior Physicians Seen
ment or clarify this data. Patients were excluded if intake forms
0 91 (35.1)
were missing or the duration of the complaint could not be
assessed. 1 94 (36.3)
Demographic information was compiled, along with infor- 2 48 (18.6)
mation regarding onset of complaint, characteristics and history 31 26 (10.0)
of the hoarseness, alcohol and tobacco use, surgical history,
medications, quality-of-life indicators, Voice Handicap Index-10 VHI 5 Voice Handicap Index.
(VHI-10), and Singers Voice Handicap Index-10 (SVHI-10),
where applicable. In addition, information regarding previous
calculated to examine the effect of hoarseness severity on time
medical care and physician visits was obtained.
to presentation. Furthermore, categories for the total length of
The date of hoarseness onset and the dates of prior physi-
complaint—time from symptom onset to subspecialty evalua-
cian visits, procedures, and treatments were recorded. When
tion—were created (0 to 3 months; > 3 months to 1 year; and > 1
exact dates were unavailable, they were approximated using a
year), and the distribution of final diagnoses in each group was
best estimate. For example, if the patient reported seeing a phy-
evaluated.
sician in October 2013, the date was approximated as October
Diagnostic data was used to investigate discrepancies
1, 2013. If a patient reported the problem start date as “many
between incoming diagnoses and final diagnoses after subspeci-
years ago,” the duration of the complaint was estimated as 7
alty evaluation. Discrepancies between the incoming and final
years (unless a better estimate could be obtained from the his-
diagnoses were calculated for each diagnostic category. In addi-
tory). If a patient reported lifetime issues with hoarseness but
tion, relationships between a variety of specific variables—
had recently worsened, the period of worsening symptoms was
including medical history, demographic data, previous evalua-
considered to be the current complaint.
tive procedures, and prior treatment—were investigated to
All incoming diagnoses (those given by previous providers)
answer specific questions. For example, data regarding prior
and final diagnoses were recorded. We attempted to minimize
treatment was used to investigate patterns of antibiotic pre-
the effect of the lack of uniform diagnostic terminology by creat-
scription in the infectious category, and data regarding proce-
ing broad, inclusive diagnostic categories: 1) cyst, polyp, or
dures was used to investigate the use of esophagoscopy.
benign mass; 2) vocal fold paresis; 3) vocal fold paralysis; 4)
Descriptive statistics were used along with statistical tests, spe-
neurological disorders–other (other than paresis or paralysis;
cifically analysis of variance (ANOVA), where applicable.
e.g., adductor spasmodic dysphonia, Parkinson’s disease); 5)
infection or allergy; 6) edema or laryngopharyngeal reflux dis-
ease (LPR); 7) sulcus, atrophy, or scar; 8) muscle tension dys- RESULTS
phonia (MTD) or behavioral disorder; 9) malignancy; and 10) A total of 259 new patients with voice complaints
other (e.g., musculoskeletal injury, trauma). presented for subspecialty evaluation between July 16,
The dates for each physician visit were used to determine 2013, and November 19, 2013. Demographic informa-
the order of doctors seen. For patients who had seen a prior
tion is summarized in Table I. Sixty-one percent of
physician, the mean number of prior visits was calculated,
patients saw an otolaryngologist prior to subspecialty
along with the mean number by diagnostic category. The com-
plaint start date, dates of prior medical evaluation, current visit evaluation, and 9.7% initially presented to a primary
date, and procedural information were used to determine care physician (PCP), emergency room physician, or
median times to primary medical evaluation, laryngoscopy, “other” specialist. Sixty-one percent of patients had lar-
stroboscopic exam, and subspecialty evaluation. Median time to yngoscopy, and 14.7% had stroboscopy prior to subspeci-
first physician evaluation by VHI-10 category was also alty evaluation.

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Fig. 1. Average number of prior physicians seen (for patients seen by another physician, n 5 168) across the 10 diagnostic categories. One-
way ANOVA demonstrated statistically significant difference between groups (F [9, 158], 2.03; P value, 0.04).
For the 64.9% (n 5 168) of patients who had seen a
prior physician, the average number of previous doctor
visits was 1.71 (standard deviation 5 1.06), with a range
of 1 to 7. The mean number of prior physician visits was
compared across final diagnosis categories (Fig. 1).
There was a statistically significant difference between
the groups, as determined by one-way ANOVA (F [9,
158] 5 2.03, P value 5 0.04), which may identify chal-
lenging diagnoses. Final diagnoses with the highest
average number of prior physician visits were neurologi-
cal disorders–other, paresis, and malignancy. The
median times from symptom onset to primary evalua-
tion, diagnostic procedures, and specialty evaluation are
summarized in Table II. Median time from symptom
onset to first physician visit across the four different
VHI-10 categories is also shown in Table II.
Proportions of final diagnoses observed for each of
the three length of complaint categories are shown in
Figure 2. Several diagnoses demonstrated marked vari-
ability. The infection or allergy category made up 20% of
total diagnoses in the 0 to 3 months category, 2% of the
3 months to 1 year category, and 3% of the greater than
1 year category. Sulcus, atrophy, or scar diagnoses made
up 2%, 7%, and 28% of those categories, respectively,
whereas neurological disorders–other represented 1%,
5%, and 11%.
There were a total of 209 incoming diagnoses for
168 patients who had seen a prior physician. Forty-five
percent of incoming diagnoses were revised by the sub-
specialist (Supp. Fig. S1; online-only) and for those
revised, the most common final diagnoses were: vocal
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fold paresis (16%); sulcus, atrophy, or scar (9%); cyst,
polyp, or benign mass (8%); and neurological disorders–
other (4%).
The final diagnoses with the highest proportion of
discrepancy from incoming diagnoses (Table III)
included: MTD or behavioral (100%; n 5 5); paresis (87%;
n 5 38); malignancy (71%; n 5 7); and sulcus, atrophy, or
scar (69%; n 5 29). Patients with a final diagnosis of
malignancy had a total of seven instances of prior diag-
noses. Of these, only two were diagnoses of possible
malignancy. The other five included edema or LPR (3),
infection or allergy (1), and benign mass (1). Of 38 final
diagnoses of paresis, 37% were revised from an initial
diagnosis of edema or LPR, 21% from infection or
allergy, 11% from benign mass, 11% from paralysis, and
3% from no abnormality.
The incoming diagnoses most commonly revised by
the subspecialist (Table IV) included the following: no
abnormality (100%; n 5 7); MTD or behavioral (100%;
n 5 2); edema or LPR (93%; n 5 41); and infection or
allergy (87%; n 5 31). Of 41 incoming diagnoses of reflux,
34% were revised to paresis; 22% to sulcus, atrophy, or
scar; and 15% to a benign mass. Similarly, of 31 incom-
ing diagnoses of infection or allergy, 26% were revised to
benign mass; 26% to paresis; and 16% to sulcus, atrophy,
or scar.
In order to evaluate the cost of such discrepancies,
we analyzed the use of antibiotic treatment and esopha-
goscopy in our cohort. Twenty-two patients with a prior
diagnosis of infection presented to subspecialty care for
an ongoing complaint of hoarseness. Of these, 64%
Keesecker et al.: Patterns in the Evaluation of Hoarseness
3
 TABLE II.
Median Times from Symptom Onset to First Physician Visit or Diagnostic Procedure
Median Time to First Physician Visit or Diagnostic Procedure
Median (m) Q1 25% (m) Q2 75% (m) Minimum (d) Maximum (y)

First physician visit 3.0 0.9 12.0 0.0 20.0

First laryngoscopy 3.0 1.0 12.0 0.0 20.0
First stroboscopy 5.8 2.0 16.6 1.0 32.7
Subspecialty visit 6.6 2.3 21.2 1.0 32.7
Median Time to First Physician Visit by VHI-10 Category
[1–9] [10–19] [20–29] [30–40]

First physician visit 3.02 3.06 4.39 1.02

d 5 days; m 5 months; q 5 quartile; y 5 years.

(n 5 14) had received at least one round of antibiotic
treatment without resolution of their symptoms. How-
ever, upon subspecialty evaluation, only 14% (n 5 3) were
given a final diagnosis of infection. In addition, a subset
of seven patients out of a total of 39 previously diagnosed
with reflux underwent esophagoscopy for this presumed
diagnosis. However, none of these patients received a
final diagnosis of reflux. In this subset, the final diagno-
ses included vocal fold paresis (n 5 1); adductor spasmodic
dysphonia (n 5 1); and sulcus, atrophy, or scar (n 5 5).
DISCUSSION
In the studied cohort, most patients presented
directly to an otolaryngologist (55.2% were initially
evaluated by an otolaryngologist other than the senior
author [S.E.K.]; 35.1% presented directly to subspecialty
care). The median times from symptom onset to
first presentation based on VHI-10 category (Table II)
demonstrated that patients with more severe hoarseness
(VHI-10 score of 30–40) presented to a physician sooner.
The median time from symptom onset to first physician
visit as well as symptom onset to first laryngoscopy was
3 months (Table II). This is consistent with a pattern of
early specialty care and indicates that patients received
prompt laryngeal visualization upon presentation, sub-
stantially sooner than the 3 months proposed by the
American Academy of Otolaryngology–Head and Neck
Surgery guidelines.4 Prior studies have demonstrated
the importance of laryngoscopy in accurately diagnosing
laryngeal disorders, given the inaccuracy of history and
physical exam alone.6,8

Fig. 2. Diagnoses based on total length of complaint categories. The distribution of diagnoses observed in three separate categories based
on total length of complaint. Total length of complaint was calculated from symptom onset to evaluation by the subspecialist.

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 TABLE III.
Final Diagnostic Category by Incoming Diagnostic Category.
B mass 5 benign mass; E/LPR 5 edema or laryngopharyngeal reflux disease; Infx/All 5 infection or allergy; Malig 5 malignancy; MTD/B 5 muscle tension
dysphonia or behavioral disorders; Neuro O 5 neurological disorders other than paresis or paralysis; No Ab 5 no abnormality; Prs 5 paresis; Pys 5 paralysis;
S/A/S 5 sulcus, atrophy, or scar.
More time elapsed to stroboscopy (median of 5.8
months from symptom onset) and to subspecialty evalua-
tion (median of 6.6 months). The role of stroboscopy in
hoarseness evaluation has not been precisely estab-
lished, despite its clinical availability for decades. Stud-
ies suggest that stroboscopy is especially likely to be
useful when continuous light laryngoscopy does not
explain the severity of the patient’s complaint, when
hoarseness persists despite treatment, and when unex-
pected hoarseness occurs after microlaryngoscopy.9–11
However, perceptions regarding its utility vary. Paul
et al.6 demonstrated that the majority of academic lar-
yngologists consider stroboscopy very valuable, whereas
private practice clinicians disagree. This perception may
account in part for the observed delay in stroboscopy.
In this study, several findings suggest which disor-
ders present particular diagnostic challenges. Patients
ultimately diagnosed with vocal fold paresis, neurological
disorders–other, and malignancy were evaluated, on aver-
age, by the highest number of prior physicians (Fig. 1).
Additionally, several diagnoses—sulcus, atrophy, scar, and
neurological disorders–other—made up a larger propor-
tion of the total diagnoses as the length of complaint
increased (Fig. 2), indicating that these patients were still
seeking care after a longer period of time. Although this
could be attributed to the chronicity of certain diseases in
these categories, it may also be driven by misdiagnosis
and inappropriate or insufficient treatment. This inter-
pretation is supported by the observation that most of the
diagnoses which resulted in multiple physician visits and
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diagnostic delay do not involve gross motion abnormal-
ities or mass lesions easily discernible on continuous-light
laryngoscopy. According to Cohen et al., otolaryngologists
tend to be less comfortable diagnosing disorders without
obvious physical abnormalities,12 which could partially
account for the discrepancies.
Almost one-half of all incoming diagnoses were
revised upon re-evaluation (Supp. Fig. S1; online only).
Final diagnoses that most frequently differed from
incoming diagnosis included MTD or behavioral disor-
ders; paresis; malignancy; and sulcus, atrophy, or scar
(Table III). Once again, diagnoses without gross motion
abnormality or mass lesion are prominently represented.
Incoming diagnoses most commonly revised included no
abnormality, MTD or behavioral disorders, edema or
LPR, and infection or allergy (Table IV), conditions with
laryngoscopic findings that are notably nonspecific and
somewhat interchangeable.
Other studies have demonstrated similar results.
For example, a recent prospective, multi-institutional
study found that 33% of patients with laryngological
complaints had a final diagnosis after subspecialty eval-
uation that disagreed with the referring diagnosis.13 The
most commonly revised referring diagnoses included
LPR (61% revised) and laryngeal dystonia (56% revised).
Similarly, a longitudinal study found that the diagnosis
of hoarseness commonly changed upon specialty evalua-
tion and also within specialty evaluation.14 Two groups
were evaluated: 1) patients seen by a PCP followed by
an otolaryngologist, and 2) patients seen at least twice
Keesecker et al.: Patterns in the Evaluation of Hoarseness
5
 TABLE IV.
Incoming Diagnostic Category by Final Diagnostic Category.
B mass 5 benign mass; E/LPR 5 edema or laryngopharyngeal reflux disease; Infx/All 5 infection or allergy; Malig 5 malignancy; MTD/B 5 muscle tension
dysphonia or behavioral disorders; Neuro O 5 neurological disorders other than paresis or paralysis; No Ab 5 no abnormality; Prs 5 paresis; Pys 5 paralysis; S/
A/S 5 sulcus, atrophy, or scar.
by an otolaryngologist. Three-fourths of patients in the
first group and one-half in the second group received a
different diagnosis upon specialty evaluation. In both
cohorts, acute laryngitis was the most commonly revised
diagnosis. However, the authors could not differentiate
between clinicians within a specialty (i.e., whether a
patient saw the same otolaryngologist twice or saw two
different otolaryngologists). Additionally, diagnostic data
was obtained exclusively from ICD codes, which are
notoriously vague for voice disorders. For example, scar,
sulcus, atrophy, and even reflux laryngitis have no spe-
cific code and can be coded in more than one way. Fur-
thermore, almost one-half of the subjects had to be
classified as “nonspecific dysphonia” (presumably ICD
784.42). Finally, it was impossible to determine whether
the diagnosis change was due to evolution of disease
pathology, such as acute laryngitis resolving, or a differ-
ence in opinion between providers.
Although the number of patients with malignancies
in this study is small, it deserves attention because of
the consequences of diagnostic delay. Based on our
results, 60% of the cases referred for possible malig-
nancy were actually due to benign pathology. More wor-
risome are cases that were misdiagnosed as benign and
never referred to a subspecialist. When the final diagno-
sis was malignancy, 71% of initial diagnoses were not in
agreement. These included benign mass, infection,
allergy, edema, or LPR. It is concerning that several of
these initial misdiagnoses represent nonspecific condi-
tions. Cohen et al.15 have shown that these are less
likely to generate specialty referral.
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6
An intelligent recommendation for specialty refer-
ral—and perhaps subspecialty referral—is clearly
needed. The 2-week interval traditionally used is broadly
consistent with the interval in which a self-limited con-
dition such as viral laryngitis would be expected to
resolve, which underlies its rationale. The 3-month
interval proposed in the Academy guidelines4 stretches
well beyond that and may carry harm from delay in
diagnosis. The only potential benefit is cost, assuming
longer-lasting self-limited pathologies, but this is uncer-
tain given the spectrum of possible diagnoses persisting
beyond 2 weeks, as well as the cost of inappropriate test-
ing and treatment. Therefore, this may be a false econ-
omy to the detriment of the patient.
Although there is clear consensus that visualizing
the larynx is necessary for diagnosis,6–8 it appears that
it is not always sufficient. A consistent group of diagno-
ses (paresis, sulcus, atrophy, scar, and neurologic disor-
ders other than peripheral neuropathy) resulted in more
physician visits and delay in diagnosis. Sulcus, atrophy,
scar, and paresis are notoriously difficult to diagnose on
continuous light examination. The subject of referral for
stroboscopy has been virtually untouched in the litera-
ture, but data suggests that it should be considered in
patients with hoarseness and no evident abnormality on
laryngoscopy. Furthermore, practitioners should consider
stroboscopy for patients diagnosed with inflammatory
conditions marked by nonspecific findings—such as
LPR, infection, or allergy—if they do not respond to
treatment promptly. This is at odds with current recom-
mendations for reflux, which encourage long-term
Keesecker et al.: Patterns in the Evaluation of Hoarseness
empiric treatment, but is consistent with other studies
regarding reflux13 and acute laryngitis.14 Clinical com-
mon sense dictates that for hoarseness, examination of
the sound source is likely to be more revealing than
examination of the stomach and esophagus.
As with diagnostic delay, inaccurate diagnosis has a
dollar value and potential morbidity related to unneces-
sary procedures and treatments. Forty-one patients in
this study received an initial diagnosis of LPR. Seven
underwent esophagoscopy, none of which received a final
diagnosis of reflux. Several of these patients had more
extensive work-ups with other ultimately unhelpful pro-
cedures and treatments. For example, one patient—a 50-
year-old woman with hoarseness and cough since partial
thyroidectomy in 2009—had been evaluated by three
otolaryngologists, a gastroenterologist, an allergist, and
a pulmonologist. Her prior work-up included allergy
testing, bronchoprovocation challenge testing, esophago-
scopy, barium swallow, pH monitoring, laryngoscopy, and
stroboscopic exam. On presentation to the subspecialist,
she was diagnosed with vocal fold paresis with neuro-
genic cough and has since reported near-complete relief
with injection augmentation and tramadol.
This study has limitations related to methodology,
patient population, and diagnostic ambiguities. The
study is a retrospective review of data from a single cen-
ter. In addition, the data is largely patient-reported and
therefore limited by the patients’ ability to understand
and recall medical information. However, many patients
continued to seek care for persistent symptoms, making
a correct initial diagnosis less likely. Because of the
nature of the data, we did not expect to capture the full
picture and scope of evaluation for every patient. How-
ever, additional instances of physician visits, diagnosis,
and management would probably further amplify the
reported findings and further substantiate the demon-
strated inefficiencies. An additional limitation is the fact
that we combined certain diagnoses into diagnostic cate-
gories. Although this may cause some loss of detail in
the analysis, the measure was necessary to minimize the
effect of variability in nomenclature (e.g., nodule, mid-
fold mass, and fibrovascular midfold lesion—all referring
to similar pathology). We believe that the categories are
clinically valid and as detailed, or more detailed, than
available in similar literature.
In this project, we presumed that the final diagno-
sis given by the subspecialist was the most “correct.”
However, excluding certain diagnoses for which patho-
logic correlation exists, such as malignancy, or that yield
pathognomonic findings, such as sulcus and paralysis,
there is no final standard for diagnosis. We recognize
that many laryngological diagnoses rest on expert opin-
ion, and some are notoriously subjective. Finally, this
study examines only patients presenting to subspecialty
care for persistent hoarseness. This may represent less
than 10% of patients with hoarseness.15 However, many
of these patients represent individuals whose complaints
have not been adequately addressed by prior physicians,
and thus may be the most useful group to examine in
order to address the efficiency of evaluation.
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CONCLUSION
For patients presenting with hoarseness, median
times from symptom onset to first physician visit and to
laryngoscopy were equal, which indicates that patients
received prompt laryngeal visualization. We observed
high rates of discrepancy between incoming diagnoses
and final diagnosis after subspecialty evaluation, which
included stroboscopy. This was particularly true for
patients initially diagnosed with inflammatory or infec-
tious conditions with relatively nonspecific findings,
such as reflux, allergy, or infection. Patients ultimately
diagnosed with sulcus, atrophy, scar, paresis, and neu-
rologic disorders other than paresis or paralysis sought
care for longer and from more physicians, and account
for a disproportionate number of discrepancies between
initial and final diagnosis. Given the importance of lar-
yngoscopy for diagnosis and the time-sensitive nature
of treatment for malignancy, practitioners should con-
tinue to visualize the larynx without delay in the
hoarse patient. Additionally, practitioners should be
aware that certain laryngeal pathologies may be diffi-
cult to diagnose with continuous light endoscopy and
that nonspecific inflammatory diagnoses may mask
underlying pathology, incur unnecessary expense, and
delay appropriate treatment. In patients who do not
respond to treatment promptly, further laryngeal
evaluation and/or subspecialty referral should be con-
sidered before embarking on prolonged empiric treat-
ment or diagnostic investigations directed away from
the larynx.
BIBLIOGRAPHY
1. Roy N, Merrill RM, Gray SD, Smith EM. Voice disorders in the general
population: prevalence, risk factors, and occupational impact. Laryngo-
scope 2005;115:1988–1995.
2. Cohen SM. Self-reported impact of dysphonia in a primary care popula-
tion: an epidemiological study. Laryngoscope 2010;120:2022–2032.
3. Rosen CA, et al. Advances in office-based diagnosis and treatment in lar-
yngology. Laryngoscope 2009;119(suppl 2):S185–S212.
4. Schwartz SR, et al. Clinical practice guideline: hoarseness (dysphonia).
Otolaryngol Head Neck Surg 2009;141(suppl 2):S1–S31.
5. Hoare T, Thomson H, Proops D. Detection of laryngeal cancer—the case
for early specialist assessment. J R Soc Med 1993;86:390–392.
6. Paul BC, Branski RC, Amin MR. Diagnosis and management of new-onset
hoarseness: a survey of the American Broncho-Esophagological Associa-
tion. Ann Otol Rhinol Laryngol 2012;121:629–634.
7. Sadoughi B, Fried MP, Sulica L, Blitzer A. Hoarseness evaluation: a trans-
atlantic survey of laryngeal experts. Laryngoscope 2014;124:221–226.
8. Paul BC, Chen S, Sridharan S, Fang Y, Amin MR, Branski RC. Diagnostic
accuracy of history, laryngoscopy, and stroboscopy. Laryngoscope 2013;
123:215–219.
9. Casiano R, Zaveri V, Lundy D. Efficacy of videostroboscopy in the diagno-
sis of voice disorders. Otolaryngol Head Neck Surg 1992;107:95–100.
10. Sataloff R, Spiegel J, Hawkshaw M. Strobovideolaryngoscopy: results and
clinical value. Ann Otol Rhinol Laryngol 1991;100:725–727.
11. Woo P, Casper J, Colton R, Brewer D. Diagnosis and treatment of persis-
tent dysphonia after laryngeal surgery: a retrospective analysis of 62
patients. Laryngoscope 1994;104:1084–1091.
12. Cohen SM, Pitman MJ, Noordzij JP, Courey M. Evaluation of dysphonic
patients by general otolaryngologists. J Voice 2012;26:772–778.
13. Solowski N, et al. Accuracy of referral diagnosis: a laryngological perspec-
tive. In: American Brochoesophagological Association Session of the
116th COSM meeting. Orlando, Florida, USA; April 10, 2013.
14. Cohen SM, Dinan MA, Roy N, Kim J, Courey M. Diagnosis change
in voice-disordered patients evaluated by primary care and/or otolaryn-
gology: a longitudinal study. Otolaryngol Head Neck Surg 2014;150:
95–102.
15. Cohen SM, Kim J, Roy N, Courey M. Factors influencing referral of
patients with voice disorders from primary care to otolaryngology.
Laryngoscope 2014;124:214–220.
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